US VISA APPLICATION DRAFT FORM – 2019

PERSONAL INFORMATION
PARTICULAR ANSWER REMARKS
Surnames Enter all surnames as listed in your
passport. If only one name is listed in
(e.g., FERNANDEZ GARCIA) your passport, enter that Surname.
Given Names
If your passport does not include a
(e.g., JUAN MIGUEL) given name, please enter 'FNU' in
Given Names.
Full Name in Native Alphabet DOES NOT APPLY
Have you ever used other names Other names used include your
YES NO maiden name, religious name,
(i.e., maiden, religious, professional,
professional name, or any other
alias, etc.)? If yes, please provide names which you are known by or
details have been known by in the past.

Do you have a telecode that Telecodes are 4 digit code numbers

YES NO that represent characters in some
represents your name? non-Roman alphabet names.

Sex MALE FEMALE

Married Common Law Marriage
Civil Union/Domestic Partnership
Marital Status
Single Widowed Divorced
Legally Separated
If day or month is unknown, enter as
Date of Birth (mm/dd/yyyy) shown in passport.

City/State/Province of Birth

Country of Birth

Country/Region of Origin (Nationality)

Do you hold or have you held any
nationality other than the one YES NO
indicated above on nationality?
Permanent resident means any
Are you a permanent resident of a individual who has been legally
country/region other than your granted by a country/region
YES NO permission to live and work without
country/region of origin (nationality)
time limitation in that
indicated above? country/region.
Your National ID Number is a unique
National Identification Number DOES NOT APPLY number that your government
provides. The U.S. Government
U.S. Social Security Number DOES NOT APPLY provides unique numbers to those
who seek employment (Social
Security Number) or pay taxes
U.S. Taxpayer ID Number DOES NOT APPLY (Taxpayer ID).

TRAVEL INFORMATION
Purpose of Trip to the U.S.
Intended Date of Arrival
(Format: DD-MMM-YYYY) If you are unsure of your travel plans,
please provide an estimate.
Intended Length of Stay in U.S. Day(s) Week(s) Month(s)
Address Where You Will Stay in the
U.S. (provide full address with Zip Code)
Person/Entity Paying for Your Trip Self Other
(if other, please provide Full Name and your
relationship to your sponsor)

TRAVEL COMPANIONS
Are there other persons traveling with You should answer Yes to this
YES NO question if you are traveling with
you? family, as part of an organized tour
YES NO If yes, provide name of group
Are you travelling as part of a group or
organization?

1.

Enter person(s) travelling with you 2.

(provide surname, full name and their relationship Use another sheet of paper should
with you – Parent/Spouse/Child/Other the space provided is insufficient
Relative/Friend/Business Associate) 3.

4.

PREVIOUS U.S. TRAVEL INFORMATION

YES NO

1.
Have you ever been in the U.S.?
2.
(If yes, Please provide dates of travel
and duration of stay of your last five
3.
(5) US trips )
4.

5.
Enter the 8-digit number that is
YES NO
displayed in red on the lower right
Have you ever been issued a U.S. hand side of your visa. If your
Date of Issue: previous visa was a Border Crossing
Visa? (If yes, please provide details) Card enter the last 12-digit number of
the first line of the machine readable
Visa Number: zone.

Are you applying for the same type of

YES NO
visa?
Are you applying in the same country
where the visa above is issued and is
YES NO
this country your principal country of
residence?
Ten-printed means that you have
provided fingerprints for all your
Have you been ten-printed? YES NO fingers, as opposed to having
provided only two fingerprints.
Has your U.S. Visa ever been lost or
YES NO
stolen?
Has your U.S. Visa ever been cancelled
YES NO
or revoked?
Have you ever been refused a U.S. YES NO If yes, explain
Visa, or been refused admission to the
United States, or withdrawn your
application for admission at the port
of entry?
Has anyone ever filed an immigrant
YES NO If yes, explain
petition on your behalf with the
United States Citizenship and
Immigration Services?

ADDRESS AND PHONE INFORMATION

Street Address (Line 1)

Street Address (Line 2)

City

State/Province

Postal Zone/ZIP Code

Country/Region
Is your Mailing Address the same as
YES NO
your Home Address?
You must provide a primary phone
Primary Phone Number number. The primary phone number
should be the phone number at
which you are most likely to be
Secondary Phone Number reached; this could be a land line or a
cellular/mobile number. If you have
an additional land line or a
Work Phone Number cellular/mobile number please list
that as your secondary phone
number.
Have you used any other phone
YES NO
numbers in the last five years?
You must provide an email address.
The email address you provide will be
used for correspondence purposes.
Email Address Provide an email address that is
secure and to which you have
reasonable access.
Have you used any other email
YES NO
addresses in the last five years?
Enter information associated with
Do you have a social media presence? YES NO your online presence, including the
types of online providers/platforms,
Facebook Instagram Youtube applications and websites that you
Social Media Provider/Platform
Linkedin Twitter use to collaborate, share information,
(Select all that are applicable) and interact with others. List the
Others, please specify username, handle, screen-name, or
other identifiers associated with your
Social Media Identifier social media profile.
Do you wish to provide information
about your presence on any other
websites or applications you have
YES NO
used within the last five years to
create or share content (photos,
videos, status updates, etc.)?
PASSPORT INFORMATION
Regular Official Diplomatic Enter the information on the travel
document you will be using when
Passport/Travel Document Type Laissez-Passer traveling to the U.S. Your travel
Others, please specify document should be a valid,
unexpired passport or other valid,
unexpired documentation that is
Passport/Travel Document Number sufficient to establish your identity
and nationality.

Passport Book Number DOES NOT APPLY

Country/Authority That Issued
Passport/Travel Document
City Where Passport was Issued
State/Province Where Passport was
Issued (if shown in passport)
Country/Region Passport was Issued

Date Passport was Issued

Date of Expiry
Have you ever lost a passport or had
YES NO
one stolen?

U.S. POINT OF CONTACT INFORMATION

Your U.S. Point of Contact can be any
Surname individual in the U.S. who knows you
and can verify, if necessary, your
identity. If you do not personally
Given Names know anyone in the U.S., you may
enter the name of the store,
Organization Name company, or organization you plan to
visit during your trip.
Relative Spouse Friend
Business Associate Employer
Relationship to you
School Official
Other, please specify
U.S. Street Address

City

State

Zip Code

Phone Number

Email Address

FAMILY INFORMATION : RELATIVES

Father’s Surname

Father’s Given Names

Father’s Date of Birth

Is your father in the U.S. YES NO

Mother’s Surname

Mother’s Given Names

Mother’s Date of Birth

Is your mother in the U.S. YES NO

Means fiancé/fiancée, spouse
Do you have any immediate relatives, YES NO (husband/wife), child (son/daughter),
or sibling (brother/sister).
not including parents, in the United
States? 1.

if yes, please provide the ff: 2.

Surname Use another sheet of paper should
Given Names the space provided is insufficient
Relationship to you – Spouse/Fiance/Child/Sibling 3.
Relative’s Status – US Citizen/US Legal Permanent
Resident/Non Immigrant/Other 4.
Do you have any other relatives in the
YES NO
United States?

FAMILY INFORMATION : SPOUSE

Spouse’s Surname

Spouse’s Given Names

Spouse’s Date of Birth

Spouse’s City of Birth

Spouse’s Country of Birth

Same as home address
Same as mailing address
Spouse’s Address Same as U.S. Contact Address
Do not know
Others, please specify

PRESENT WORK/EDUCATION/TRAINING INFORMATION

Agriculture Business
Communications Culinary/Food
Education Engineering
Government Homemaker
Legal Profession Medical/Health
Primary Occupation
Millitary Natural Science
Not Employed Physical Sciences
Religious Vocation Research
Social Science Student
Others, please specify
Employer or School Street Address

City

State/Province

Zip Code

Phone Number

Country

Start Date (mm/dd/yyyy)

Monthly Income in Local Currency

Briefly describe your duties

PREVIOUS WORK/EDUCATION/TRAINING INFORMATION

Were you previously employed? YES NO If yes, please provide details

Employer Name

Employer Street Address

City

State/Province

Zip Code

Phone Number

Country

Job Title

Supervisor’s Surname

Supervisor’s Given Name

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Briefly describe your duties

 You must answer Yes to this question
if you have ever attended, for any
Have you attended any educational length of time, a high
school/secondary school (or its
institutions at a secondary level or YES NO If yes, please provide details equivalent in your country) or
above? college, university, graduate school, a
doctoral program, or a vocational
program.

Name of Institution

Employer Street Address

City

State/Province

Zip Code

Phone Number

Country
For middle school/junior high or high
school course of study please indicate
Course of Study “Academic” or “Vocational.” For all
other educational levels please
indicate your major or concentration.

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

ADDITIONAL WORK/EDUCATION/TRAINING INFORMATION

Do you belong to a clan or tribe? YES

Provide a List of Languages You Speak

YES NO If yes, please provide details

1.

Have you traveled to any 2.

countries/regions within the last five
years? 3.

4.

5.
Have you belonged to, contributed to, YES NO If yes, please explain
or worked for any professional, social,
or charitable organization?
Do you have any specialized skills or YES NO If yes, please explain
training, such as firearms, explosives,
nuclear, biological, or chemical
experience?
 YES NO If yes, please explain
Have you ever served in the military?

Have you ever served in, been a

member of, or been involved with a
paramilitary unit, vigilante unit, rebel YES NO If yes, please explain
group, guerrilla group, or insurgent
organization?

SECURITY AND BACKGROUND INFORMATION

Do you have a communicable disease of public YES NO If yes, please explain
health significance? (Communicable diseases
of public significance include
chancroid, gonorrhea, granuloma inguinale,
infectious leprosy, lymphogranuloma
venereum, infectious stage syphilis, active
tuberculosis, and others diseases as
determined by the Department of Health and
Human Services.)
Do you have a mental or physical disorder that YES NO If yes, please explain
poses or is likely to pose a threat to the safety
or welfare of yourself or others?

Are you or have you ever been a drug abuser YES NO If yes, please explain
or addict?

Have you ever been arrested or convicted for YES NO If yes, please explain
any offense or crime, even though subject of a
pardon, amnesty, or other similar
action?
Have you ever violated, or engaged in a YES NO If yes, please explain
conspiracy to violate, any law relating to
controlled substances?

Are you coming to the United States to engage YES NO If yes, please explain
in prostitution or unlawful commercialized vice
or have you been engaged in
prostitution or procuring prostitutes within the
past 10 years?
Have you ever been involved in, or do you seek YES NO If yes, please explain
to engage in, money laundering?

Have you ever committed or conspired to YES NO If yes, please explain

commit a human trafficking offense in the
United States or outside the United States?

Are you the spouse, son, or daughter of an YES NO If yes, please explain
individual who has committed or conspired to
commit a human trafficking offense in
the United States or outside the United States
and have you within the last five years,
knowingly benefited from the trafficking
activities?
Have you knowingly aided, abetted, assisted or YES NO If yes, please explain
colluded with an individual who has
committed or conspired to commit a severe
human trafficking offense in the United States
or outside the United States?
Do you seek to engage in espionage, sabotage, YES NO If yes, please explain
export control violations, or any other illegal
activity while in the United States?

Do you seek to engage in terrorist activities YES NO If yes, please explain

while in the United States or have you ever
engaged in terrorist activities?

Have you ever or do you intend to provide YES NO If yes, please explain
financial assistance or other support to
terrorists or terrorist organizations?

Are you a member or representative of a YES NO If yes, please explain

terrorist organization?

Are you the spouse, son, or daughter of an YES NO If yes, please explain
individual who has engaged in terrorist
activity, including providing financial
assistance or other support to terrorists or
terrorist organizations, in the last five years?
Have you ever ordered, incited, committed, YES NO If yes, please explain
assisted, or otherwise participated in
genocide?

Have you ever committed, ordered, incited, YES NO If yes, please explain
assisted, or otherwise participated in torture?

Have you committed, ordered, incited, YES NO If yes, please explain

assisted, or otherwise participated in
extrajudicial killings, political killings, or other
acts of
violence?
Have you ever engaged in the recruitment or YES NO If yes, please explain
the use of the child soldiers?

Have you, while serving as a government YES NO If yes, please explain

official, been responsible for or directly carried
out, at any time, particularly severe
violations of religious freedom?
Are you a member of or affiliated with the YES NO If yes, please explain
Communist or other totalitarian party?

Have you ever disclosed or trafficked in YES NO If yes, please explain

confidential U.S. business information
obtained in connection with U.S. participation
in the
Chemical Weapons Convention?
Have you ever been the subject of a removal YES NO If yes, please explain
or deportation hearing?

Have you ever sought to obtain or assist others YES NO If yes, please explain
to obtain a visa, entry into the United States,
or any other United States
immigration benefit by fraud or willful
misrepresentation or other unlawful means?
Have you failed to attend a hearing on YES NO If yes, please explain
removability or inadmissibility within the last
five years?

Have you ever been unlawfully present, YES NO If yes, please explain
overstayed the amount of time granted by an
immigration official or otherwise violated
the terms of a U.S. visa?
Have you ever been removed or deported YES NO If yes, please explain
from any country?

Have you ever withheld custody of a U.S. YES NO If yes, please explain
citizen child outside the United States from a
person granted legal custody by a U.S.
court?
Have you voted in the United States in YES NO If yes, please explain
violation of any law or regulation?

Have you ever renounced United States YES NO If yes, please explain
citizenship for the purpose of avoiding
taxation?

Have you attended a public elementary school YES NO If yes, please explain
on student (F) status or a public secondary
school after November 30, 1996
without reimbursing the school?